PHM-Exch> Practical example of utilizing a HRBA in the local supply of basic health services

[Claudio Schuftan]

>From Human Rights Talk: multiple.contributors at undp.org

<multiple.contributors at undp.org>*Ivan Mendoza; Abelardo Quezada; Thanalí
Patruyo, UNDP **Guatemala** :*



As way of introduction, the UNDP Guatemala is supporting the Guatemalan
Ministry for Public Health and Social Welfare in incorporating the human
rights-based approach (HRBA) into its initiatives to extend the reach of
basic health services (BHS), the ultimate aim being to improve the conduct
and performance of suppliers (DBs: duty bearers) throughout the *process* of
providing BHS to right-holders (RHs)*.* Although the right-holders are
essentially the entire population living in the areas covered by the
project, the initiative will in fact focus primarily on people facing
situations of vulnerability, such as children and women.



Our aim is to analyze the conduct of BHS suppliers and compare this with key
standards and principles of human rights: cultural belonging,
non-discrimination, accountability and participation. Our studies into
causality, patterns and capability gaps will unearth opportunities to
enhance institutional performance when providing the community with BHS.



Recommendations will be forwarded to the Ministry for Health to overcome the
capability gaps identified in the analyses. Furthermore, training schemes
will be planned for suppliers and operators alike, and good practices will
be highlighted and used to shape policies and train technical officers at
the Ministry.



We would like to make the following comments in response to the questions
arising from the first part of the debate:



*1.               Could you share some recent experiences in which work on
human rights proved to be an essential element for accomplishing specific
MDGs? If so, we would be grateful if you could share any innovative aspects
or key elements for successfully reaching such goals, indicating how and why
they worked.*

One of the underlying reasons for the project we are currently developing is
precisely the absence of projects in which the human rights-based approach
played a role in the local supply of basic health services. This project is
being carried out in four stages: as an initial stage, *gaps were studied* in
August 2009. This revealed that in relation to the basic services that the
Guatemalan Ministry for Public Health and Social Welfare (MSPAS) provides
through the Coverage Extension Program (*Programa de Extensión de Cobertura*,
or PEC), there are significant limitations when it comes to respecting the
principles of non-discrimination, cultural belonging, participation and
accountability, which are the four principles through which the project is
articulating the human rights-based approach. To elaborate further, the
analysis throughout the different communities seeks to answer questions such
as: what are the problems associated with providing healthcare services in
terms of the standards and principles of chosen human rights (vulnerability
analysis)? Who should act with a view to remedying the problem? In other
words, who are the DBs and the RHs (analysis of roles/patterns)? What are
the capability gaps of the DBs and RHs preventing them from discharging
their duties and claiming their rights, respectively? As a result, there is
a raft of problems that can be pooled into*seven gaps*, which drag back the
right of everyone to enjoy the highest possible state of health in the
process of providing local services – we are dealing with capability gaps of
suppliers (DBs) and marginalized people (RHs):



a) Gap between needs and resources

b) Gap in territorial distribution

c) Gap in the labor conditions of Basic Health Teams (BHTs)

d) Gap in citizen competences

e) Gap in the introduction and training of the BHTs

f) Gap in communication capacity

g) Gap in accountability



Following on from the findings of the gap study, the second stage of the
project involved the development of a methodological approach currently
being implemented throughout the 9 communities taking part in the pilot
scheme, this ahead of its eventual validation and adoption by PEC
management. The proposed methodology consists of an *awareness and training
stage* on the right to health and the human rights approach with the groups
involved in providing the services: DBs (both service providers and
community and municipal authorities) and RHs (encompassing both those
belonging to community organizations and users in general), before then
taking the form of participatory workshops to construct a mechanism for
participation and accountability, to which the various groups are committed.



The training sessions can also serve as an ideal opportunity to involve
suppliers in the task of unearthing solutions. The idea is to generate an
installed capacity in the program that we can continue to use with new
groups and suppliers. In the following stage of implementation, the agreed
mechanisms are deployed and workshops staged to reflect on the
implementation experience in order to *pinpoint and pass on good practices*.
Lastly, the plan is to *train the technical officers and politicians
attached to the ministry *in HRBAs and good practices, thus helping the
ministry to generate policies and define and shape the new healthcare law
currently on the table.



*2.       Bearing in mind the lessons and challenges raised  by the
Secretary General in Keeping the Promise, could you provide further details
of any strategy/example that could help to meet specific MDGs? More
specifically, in relation to:*

*·         The specific needs of the most vulnerable groups; and*

*·         Inequality and social exclusion.*

*What processes, instruments and tools have been used? What results have
been reported to date?*



The study of gaps in meeting the principles of non-discrimination,
accountability, participation and cultural belonging highlighted the need to
work individually with each and every one of the actors involved in
providing basic health services (DBs in their various guises at local level
and RHs in their various degrees of organization) so as to understand the
information they possess and the representations and meanings they entail in
relation to the process of providing the services, because it is precisely
through these conceptions and the expectations arising from them that we can
create the spaces of communication needed to gradually seal the gaps in
terms of cultural belonging, which is one of the most glaring gaps in the
supply of basic services to rural and indigenous communities in Guatemala.

In this regard, the process of incorporating the human rights-based approach
into the supply of basic health services, which is currently being
implemented through a small-scale pilot scheme, has pursued the following
strategy:

-          Mapping the actors from each of the four groups

-          Designing a training plan with different activities for different
groups, the aim being to raise awareness of the right to health and to
develop and hone skills in the human rights-based approach.

-          Developing 14 workshops, which to date have boasted the
participation of 287 participants from 9 different communities.



Following this ordering, the individual work carried out with each group at
the workshops has enabled us to identify practices and formulate proposals
on mechanisms that promote participation and accountability. Based on this
inventory and the compared experiences gleaned, we are currently commencing
the stage of generating agreements between groups through participatory
workshops used to establish the agreements governing the procedure for
implementation. Lastly, the process will be wrapped up with a support and
follow-up stage geared towards joint reflection.



3.       What are the real challenges and opportunities arising from the use
of a human rights-based approach for the purpose of attaining specific MDGs?
Did any difficulties arise during implementation, and if so provide details,
and what steps were taken to resolve them? What were the factors that
enabled the different options to work?

The law-based approach requires a change of attitude if it is to be
implemented successfully. This represents one of the greatest operational
challenges facing the project, a challenge affecting not only service
providers and local authorities, but also one that extends further up the
chain of command.

To clear a path through these obstacles, we have developed a strategy based
on disclosing information and raising awareness of the importance and
utility of being committed to incorporating the approach.



In a similar fashion, the deep roots left by the prolonged periods of
exclusion and inequality to which RHs have been exposed mean that bringing
about a change in outlook, in order for RHs to be recognized as citizens
with the right to influence and have their voice heard, is also going to be
a lengthy task involving considerable hands-on work.

Focusing on the institutional realm, another important challenge will
involve incorporating rules and regulations that reflect the rights-based
approach, focusing on the subject and not on the services. Here, strategies
target those hierarchical levels that are vested with decision-making
capacity in this regard.



As the greatest challenge facing the project naturally relates to its
sustainability, negotiations are currently being staged with PEC management
to incorporate it gradually into other jurisdictions where the program
works, although undoubtedly its sustainability will depend on the changes in
the indicators through which performance of the service providers is
currently assessed.

On a very positive note, please note that there has been definite interest
from the Coverage Extension Program, or PEC, attached to the Guatemalan
Ministry for Public Health and Social Welfare, to extend the activities
gradually to other areas of health. This expansion requires three aspects:
a) ensuring that complete documentation and records are left so that it can
be reapplied in other health-related areas. In this regard, the project is
duly documenting the entire process through an Operations Manual and
training manuals for suppliers (DBs) and users (RHs) of health services; b)
training ministry of health staff to pave the way for a subsequent expansion
process. With this in mind, the project has involved technical experts and
PEC supervisors at different stages thereof, and; c) managing financing for
the purposes of reproducing materials and funding training processes in new
areas and local activities associated with the initiatives to be undertaken.

Please *click here <http://www.uepnud.org/thanali/>* to access key documents
from the first two phases of the project, e.g. a general presentation of the
project, capacity gap study and materials from the capacity development
workshops (such as a methodological guide, facilitation guides, work guides
and support material) for four groups of participants (namely duty bearers
of the basic service teams, institutional duty bearers, organized and
non-organized rights holders). All materials are in Spanish, one work guide
is in Q'eqchi'.
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